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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application 15 Box 7302 <br /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 871/2 x 11 inches in size. <br /> County State Sani Permit Number ❑C ck if revision to previo application State Plan I.D.Number <br /> �-3 0� . a-7Ia3 <br /> I.Application Information-Please Print all Information t Location: <br /> Property Owner Name Property Location <br /> Steve & Barbara Breingan 1/4NW I/4,s 8 T40 ,N,It6 or)w <br /> Property Owner's Mailing Address Lot—Number Block Number <br /> 11568 52nd St NE 12 na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Albertville MN 55301 ( ) 1st Add Pardun's River Pine <br /> II.Type of Building: (check one) ❑city <br /> U I or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ KI Town of Oakland <br /> ❑State-Owned <br /> NearestRoai,]hitetail Trail <br /> Parcel Tax Nu mber(620-9140-02 200 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) I. Q New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Dale Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ,UNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 450 390 390 .7/1 .2 na 95.80 98.50 <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> 1000 -- 1000- 1 Wieser Concrete XX ° <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement, <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Flu is Signature o stamps): MP/MPRS No. Business Phone Number <br /> Donald Daniels MP 330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip de) <br /> PO Box 316 Siren WI 54872 <br /> IX.County/Department Use Only <br /> / ❑Disapproved Sanitary Permit F (Includes Groundwater Date Issued Issui ent Si re(No stamps) <br /> U Approved ❑Owner Given Initial Adverse Surcharge Fee) ROD, <br /> -/T <br /> Determination QM � tU/_ j <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />